Refractory facial cutaneous leishmaniasis in a child

Cutaneous leishmanasis (CL) is the most common form of leishmaniasis. The lesions are typically painless and can self-resolve. Chronic cases occur, particularly in immunocompromised patients. This report describes the treatment of a paediatric patient with refractory cutaneous leishmaniasis. Treatment of CL in children requires consideration of drug dosing, palatability, ethics of utilising treatments with limited supporting evidence and the potential long-term side effects.
An immunocompetent 13-year-old girl presented with non-healing ulcer on her face following migration from Pakistan in 2018. The lesion had persisted despite previous empiric treatment with intra-lesional sodium stibogluconate. Biopsy was performed and Leishmaniasis tropica identified by PCR. Response to topical paromomycin was poor. There was partial resolution with oral miltefosine 50 mg BD for 28 days. Re-ulceration occurred within 6 weeks of cessation. The use of liposomal amphotericin was precluded by initial anaphylaxis; desensitisation was unsuccessful. Miltefosine was restarted at a higher dose of 50 mg TDS combined with fluconazole 300 mg daily. Again there was partial response but diminished compared to previous. After 3 months, fluconazole was replaced with allopurinol 200 mg TDS for 30 days. The lesion remained static. Topical GM-CSF was subsequently added for 3 weeks, with marginal improvement. Finally, photodynamic therapy was initiated in December 2019.